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Blood Sugar Cholesterol HbA1c Ketoacidosis Ketosis LDL Type 1 Diabetes

Can Type 1s Achieve Stable, Near-Normal Blood Sugar?

14 min read

They say it's too difficult. That you have to accept the blood sugar swings. What if they're wrong?

Table of Contents

You check before breakfast. 6.2 mmol/L (112 mg/dL). Perfect.

You eat your carefully measured oatmeal—exactly 45 grams of carbs. You dose 4.5 units, just like always. Your ratio is spot-on; you've been doing this for years.

Two hours later: 13.1 mmol/L (236 mg/dL).

What happened? You measured everything. You counted precisely. You did exactly what you're supposed to do.

Your endocrinologist adjusts your ratios. Again. They remind you that some variation is normal. That you're doing well—your HbA1c is 7.2%, which meets the guidelines.
"Don't chase perfection," they say. "You'll just have more hypos."

But here's something they probably haven't told you: People without diabetes keep their blood sugar between 3.9-5.3 mmol/L (70-95 mg/dL) almost all the time. They rarely spike above 7.8 mmol/L (140 mg/dL), even after meals.

The "good control" target for Type 1? Stay between 3.9-10 mmol/L (70-180 mg/dL) at least 70% of the time.

Nearly twice the upper limit. And only 70% of the time. Following standard guidelines, most Type 1s only manage 50-60% time-in-range.

What if the problem isn't you—but the approach itself?

Why It's So Hard to Get Right

Think about what carb counting actually requires. You need to:

  1. Estimate the carbohydrates in your meal (within 10-20 grams for decent control)
  2. Match insulin timing to absorption (which varies by hours depending on fat, protein, and fiber)
  3. Dose insulin precisely (which absorbs unpredictably at higher doses)

Let's look at what research tells us about each step.

The Carb Counting Problem

The reality of carb counting is sobering. A 2013 study in Diabetes Research and Clinical Practice followed 50 adults with Type 1—experienced carb counters with an average of 21 years living with diabetes. Researchers had them keep detailed food records for 72 hours while wearing continuous glucose monitors.

The results? The average estimation error was 20% of total carbohydrate content per meal—about 15 grams off for a typical meal. And 63% of meals were underestimated.

These weren't beginners. These were people who'd been counting carbs for decades.

A broader analysis testing carb counting knowledge in adults with Type 1 found average accuracy of just 59%—and that's when people could take their time to calculate, not in real-world eating situations.

Why is it so hard?

Food labels are legally allowed to be off by 20%. That "30g carb" serving might actually be 24g or 36g. Restaurants and homemade meals? You're making educated guesses about portion sizes, hidden ingredients, and cooking methods that all affect absorption.

But here's where it gets worse.

The Insulin Timing Problem

Even if you count perfectly, you face another challenge: Different foods digest at wildly different speeds.

A plain bagel hits your bloodstream in 30 minutes. The same amount of carbs in a balanced meal with protein, fat, and vegetables might take 2-3 hours to fully absorb.

You're trying to match fast-acting insulin—which also has variable timing—to food absorption you can't predict. With a 20% margin of error on both sides.

The Insulin Dose Problem

Research shows that larger insulin doses behave less predictably. A 10-unit bolus might start working 15 minutes earlier or later than expected, depending on injection site, temperature, activity level, and factors we still don't fully understand.

The larger the dose, the larger the variation in absorption.

Dr. Richard Bernstein, who lived with Type 1 for 78 years while maintaining near-normal blood sugars, called this "the law of small numbers."

His friend Kanji Ishikawa's mantra became foundational to his approach: "Big inputs make big mistakes; small inputs make small mistakes."

It's not a failure of discipline or education. It's mathematics working against you.

You're trying to hit a moving target with a tool that has a 20% margin of error, timing something that varies by hours, using a medication that absorbs unpredictably at higher doses.

No wonder it feels impossible.

The Insight That Changes Everything

What if instead of trying to perfectly match large, unpredictable insulin doses to uncertain carbohydrate absorption...

...you simply ate far fewer carbs?

Not just "fewer" like skipping dessert. We're talking about very low carb—typically 20-50 grams daily, sometimes less.

Watch what happens to the math:

Standard Approach:

  • Meal with 80g carbs
  • Need 8 units insulin (at 1:10 ratio)
  • 20% counting error: Off by 16g carbs
  • That's 1.6 units insulin error just from carb counting
  • Add insulin absorption variability, timing mismatches, and absorption speed differences
  • Result: Blood sugar swings of 5-8 mmol/L (90-144 mg/dL) are common

Very Low Carb:

  • Meal with 10g carbs
  • Need 1 unit insulin
  • Same 20% error: Off by only 2g carbs
  • That's just 0.2 units insulin error
  • All the other variabilities are similarly reduced
  • Result: Blood sugar barely moves

The law of small numbers in action. Smaller inputs mean smaller errors mean smaller consequences.

And it's not just the carb counting error that shrinks—all the uncertainties get proportionally smaller. The insulin absorption variability, the timing mismatches, the effects of fat and protein—everything becomes more manageable when you're working with small numbers.

This isn't starvation. You eat until you're full—meat, fish, eggs, cheese, vegetables, healthy fats. Just not bread, pasta, rice, or potatoes. Most people report feeling more satisfied because protein and fat provide lasting fullness that carbs never did.

The goal isn't necessarily to stay in Ketosis all the time—though some people do, especially if they're also working on weight loss or other health improvements. The real goal is simply keeping the numbers small. Small carb intake, small insulin doses, small variations. Whether you're in ketosis or not becomes less important than the stability you achieve.

What Actually Happens: The Research

A major 2024 systematic review and meta-analysis analyzed data from 101 studies involving nearly 46,000 individuals with Type 1 diabetes. The findings were striking: reduced carbohydrate intake is associated with improved HbA1c levels and lower insulin requirements in a dose-dependent manner.

In other words, the less carbs consumed, the better the results—across thousands of patients in dozens of studies.

Real-World Results

A 2018 study published in Pediatrics surveyed 316 children and adults with Type 1 who followed a very low carb approach (averaging 36 grams daily). These were regular people—kids going to school, adults working full-time, not diabetes researchers or people with unlimited resources.

The results:

  • Average HbA1c: 5.67%—firmly in the non-diabetic range
  • Average Blood Sugar: 5.8 mmol/L (104 mg/dL)
  • Insulin requirements: Dramatically reduced from baseline

For context, standard care achieves an average HbA1c of 8.2%, with only 20% of children and 30% of adults reaching target HbA1c levels below 7%.

The study participants' average HbA1c was 7.15% before starting very low carb. After an average of 2.2 years following this approach, it dropped to 5.67%—a reduction of 1.45 percentage points.

Both children and adults achieved similar results.

Studies specifically focusing on very low carb intake (less than 50 grams daily) showed mean HbA1c results ranging from 4.0% to 6.2%. The analysis by Koutnik and colleagues found that 100% of very low carb studies achieved the American Diabetes Association target of HbA1c <7%. Even more impressive: three-quarters of all very low carb studies achieved an average HbA1c below 5.7%—the threshold for prediabetes.

What About Insulin Needs?

One of the most consistent findings: People transitioning to very low carb commonly reduce their total daily insulin dose by 25-75%, with many seeing reductions of 50% or more.

A Type 1 metabolic scientist who followed a ketogenic diet for 10 years reported improving his HbA1c to 5.5% while simultaneously reducing his insulin dose by 43%. Another long-term case study documented maintaining excellent glycemic control with reduced insulin for over a decade, with no adverse events and no detectable dysfunction in kidney, liver, thyroid, or bone mineral density.

What About Complications?

The 2018 Pediatrics study reported that only 7 participants (2%) experienced diabetes-related hospitalizations in the past year. This included 4 hospitalizations (1.3%) for ketoacidosis and 2 (0.6%) for severe hypoglycemia.

How does this compare to standard care?

Research shows that with standard management, Type 1 diabetics experience DKA at rates of approximately 20 per 1,000 patient-years (2% annually), with some studies reporting rates as high as 51 per 1,000 patient-years (5% annually). The very low carb approach achieved rates at or below typical standard care levels, despite the dramatically lower HbA1c values.

For severe hypoglycemia, the rate of 0.6% in the study is remarkably low. Standard intensive insulin therapy typically results in severe hypoglycemia rates of 16-17% annually. The very low carb participants experienced dramatically fewer episodes.

Why Haven't You Heard About This?

Here's a question worth asking: If very low carb can produce such remarkable results for Type 1 diabetes, why isn't it standard care?

Dr. David S. Ludwig, an endocrinologist and researcher at Harvard Medical School, puts it bluntly:

"For decades, the professional diabetes establishment focused almost exclusively on drug and technology development, to the neglect of research into nutritional therapies."

The lack of large randomized controlled trials isn't because the approach doesn't work—observational data from thousands of patients shows it does. It's because there's no major funding for diet studies compared to pharmaceutical research.

Dr. Ludwig continues:

"We would note that a relatively high carbohydrate diet is actively promoted to people with type 1 diabetes, despite the lack of any high quality clinical trials demonstrating superiority.
One hundred years ago, before the discovery of insulin, a very-low-carbohydrate diet was considered the most effective treatment for diabetes, including type 1. Yet to this day, there have been no major government-funded studies of a very-low-carbohydrate diet in the management of diabetes.
It sometimes takes patient activism to stimulate research into neglected treatments, and a very-low-carbohydrate diet for diabetes may be one such area."

The evidence comes from real patients achieving real results—often exceeding what the latest technology alone can provide. The 2019 ADA consensus report acknowledged this gap, noting that "clinical trials of sufficient size and duration are needed to confirm prior findings." But they're waiting for institutional support that may never come.

Meanwhile, thousands of people with Type 1 have already made the switch and achieved what they were told was impossible.

The Lower is Better Reality

Every major study examining HbA1c and complications shows the same pattern: Lower is consistently better. There's no threshold where the benefits stop.

The landmark DCCT/EDIC study followed participants for over 30 years. Even reducing HbA1c from 9% to 7%—still above non-diabetic levels—cut complications by 40-60%.

But here's what they don't often emphasize: The relationship doesn't stop at 7%. Research shows that each 1% reduction in HbA1c correlates with approximately 37% reduction in microvascular complications.

Studies looking at the general population found that mortality risk begins to increase when HbA1c exceeds 4.9%—even in people without diabetes. Within the "normal" range of 4.0-6.0%, lower is still better.

This isn't about chasing perfection for its own sake. It's about understanding that your long-term health outcomes are directly tied to your average blood sugar. The closer you can get to non-diabetic levels while avoiding hypoglycemia, the better your future looks.

And the data shows that very low carb makes this achievable without the constant battle against unpredictable blood sugar swings.

Is It Safe?

A common concern: Won't eating very low carb cause nutritional ketosis, and isn't that dangerous?

Short answer: Nutritional Ketosis is not the same as diabetic Ketoacidosis (DKA).

Nutritional ketosis produces blood ketone levels of 0.5-3.0 mmol/L—a safe, natural metabolic state that humans evolved to handle. Your body is simply burning more fat for fuel, which is exactly what it's designed to do.

DKA occurs when ketone levels exceed 10 mmol/L combined with dangerously high blood sugar (typically >15 mmol/L / 270 mg/dL) and requires immediate medical attention. It's a completely different condition.

On very low carb, your blood sugars are typically lower, not higher. You're taking less insulin, not skipping it. You're monitoring more frequently, not less.

Multiple studies have confirmed the safety of this approach with proper medical supervision. The 10-year case study mentioned earlier showed no adverse effects on kidney function, liver function, thyroid function, or bone density. Cardiovascular markers often improved despite elevated LDL Cholesterol in some cases—because the primary cardiovascular risk factor in Type 1 is high HbA1c, which this approach directly addresses.

The Decision is Yours

No one can tell you whether this approach is right for you. Only you can weigh:

  • The potential for dramatically better blood sugar control
  • Against the dietary restrictions and initial adjustment period
  • In the context of your individual life, preferences, and health goals

What we can tell you is that the results are real and reproducible. Thousands of people with Type 1 have achieved HbA1c levels in the non-diabetic range. The research backs this up across multiple studies and decades of clinical experience.

You're not being sold false hope. These aren't miracle cure claims or fringe theories. This is a well-documented approach that was standard medical practice for Type 1 diabetes for over 200 years before insulin was discovered. It's backed by solid research and real-world results from people just like you.

The mainstream diabetes establishment is slowly catching up. More endocrinologists are open to discussing this approach. More research is being published. The 2019 ADA consensus report, while cautious, acknowledged the promising results and called for more studies.

But you don't have to wait for official guidelines to change. The option exists now. The information is available. And there's a growing community of people who can share their experiences.

Is it worth trying? Only you can decide.

But at least now you know: The option exists. The results are real. And you're not alone.

Next Step

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Dive deeper

This is a detailed guide for dietitians and nutritionists, available in full text (96 pages)

Books

Scientific References

  1. Andrew P Koutnik, Thomas Wood, Kristi Storoschuk, Belinda S Lennerz. (2024). "608-P: Carbohydrate Intake, Glycemic Control, and Cardiometabolic Risk Factors in Type 1 Diabetes—A Systematic Review and Meta-regression". Diabetes, 73(Supplement_1). https://doi.org/10.2337/db24-608-P. - Systematic review of 101 studies with nearly 46,000 Type 1 participants - Clear dose-dependent relationship: lower carb intake correlates with lower HbA1c and insulin requirements - Very low carb studies (< 50g/day) showed HbA1c ranges of 4.0-6.2% - 100% of very low carb studies achieved ADA target of HbA1c <7% - 75% of very low carb studies achieved HbA1c <5.7%

  2. Belinda S Lennerz, Anna Barton, Richard K Bernstein, R David Dikeman, Carrie Diulus, Sarah Hallberg, Erinn T Rhodes, Cara B Ebbeling, Eric C Westman, Jr William S Yancy, David S Ludwig. (2018). "Management of Type 1 Diabetes With a Very Low–Carbohydrate Diet". Pediatrics, 141(6). https://doi.org/10.1542/peds.2017-3349. - 316 children and adults following very low carb (average 36g/day) - Average HbA1c: 5.67%, average blood glucose: 104 mg/dL (5.8 mmol/L) - Low rates of complications: 2% hospitalization rate (1.3% DKA, 0.6% severe hypoglycemia) - Mean HbA1c drop of 1.45% after starting approach - High satisfaction rates among participants

  3. Brazeau, A.S., et al. (2013). "Carbohydrate counting accuracy and blood glucose variability in adults with type 1 diabetes." Diabetes Research and Clinical Practice, 99(1), 19-23. - 50 experienced adults with Type 1 (21+ years duration) - Average counting error: 20% of carb content (15.4g per meal) - 63% of meals underestimated - Greater errors predicted higher glucose variability

  4. Meade, L.T., & Rushton, W.E. (2016). "Accuracy of Carbohydrate Counting in Adults." Clinical Diabetes, 34(3), 142-147. - Tested carb counting knowledge in 61 insulin-using patients - Average accuracy: 59% - Highlighted widespread challenges even among experienced counters

  5. Koutnik, A.P., et al. (2024). "Efficacy and Safety of Long-term Ketogenic Diet Therapy in a Patient With Type 1 Diabetes." JCEM Case Reports, 2(7), luae102. - 10-year case study of Type 1 patient on ketogenic diet - HbA1c improved to 5.5%, insulin dose reduced by 43% - No adverse events, no detectable dysfunction in kidney, liver, thyroid, or bone mineral density - Cardiovascular physiology superior to many non-diabetics

  6. Belinda S Lennerz, Andrew P Koutnik, Svetlana Azova, Joseph I Wolfsdorf, David S Ludwig. (2021). "Carbohydrate restriction for diabetes: rediscovering centuries-old wisdom". The Journal of Clinical Investigation, 131(1). https://doi.org/10.1172/JCI142246. - Historical context: very low carb was standard treatment for Type 1 for 200+ years pre-insulin - Reviews mechanism of action and safety profile - Addresses common concerns about nutritional adequacy - Notes lack of institutional funding for dietary research

  7. Jessica L Turton, Grant D Brinkworth, Helen M Parker, David Lim, Kevin Lee, Amy Rush, Rebecca Johnson, Kieron B Rooney. (2023). "Effects of a low-carbohydrate diet in adults with type 1 diabetes management: A single arm non-randomised clinical trial". PLOS ONE, 18(7). https://doi.org/10.1371/journal.pone.0288440. - Adults with Type 1 following low-carb intervention - Significant improvements in HbA1c and glucose variability - Insulin dose reductions ranging from 25-75% - No serious adverse events

  8. Vellanki, P., & Umpierrez, G.E. (2018). "Increasing Hospitalizations for DKA: A Need for Prevention Programs." Diabetes Care, 41(9), 1839-1841. - T1D Exchange study reported DKA incidence of ~20 cases/1,000 patient-years (2% annually) - Worldwide incidence rates in Type 1 range from 8-51 cases/1,000 patient-years - Provides context for evaluating DKA rates in different management approaches

  9. The DCCT/EDIC Study Research Group. (2016). "Intensive Diabetes Treatment and Cardiovascular Outcomes in Type 1 Diabetes: The DCCT/EDIC Study 30-Year Follow-up." Circulation, 133(25), 2660-2668. - 30+ year follow-up showing lasting benefits of tight control - Intensive control (HbA1c ~7%) reduced complications 40-60% - Demonstrated lower is consistently better for preventing complications

  10. Stratton, I.M., et al. (2000). "Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35)." BMJ, 321(7258), 405-412. - Each 1% reduction in HbA1c ≈ 37% reduction in microvascular complications - No threshold identified—lower is consistently better

  11. Khaw, K.T., et al. (2004). "Association of hemoglobin A1c with cardiovascular disease and mortality in adults: the European prospective investigation into cancer in Norfolk." Annals of Internal Medicine, 141(6), 413-420. - Mortality risk increases when HbA1c exceeds 4.9% (even in non-diabetics) - Even within "normal" range, lower HbA1c associated with better outcomes

  12. Dr. Richard Bernstein. (2014). Dr. Bernstein's Diabetes Solution: A Complete Guide to Achieving Normal Blood Sugars. Little Brown. ISBN: 0316191752 9780316191753. - Comprehensive guide based on 78+ years personal experience with Type 1 - Introduced "law of small numbers" concept: "Big inputs make big mistakes; small inputs make small mistakes" - Documented methods for near-normal blood sugars in Type 1

  13. Evert, A.B., et al. (2019). "Nutrition Therapy for Adults With Diabetes or Prediabetes: A Consensus Report." Diabetes Care, 42(5), 731-754. - 2019 ADA consensus acknowledging need for research on very low carb for Type 1 - Noted promising preliminary findings but called for larger RCTs - Recognized gap between patient success stories and institutional research

Important Note: This approach requires medical supervision, particularly during the transition when insulin doses must be significantly adjusted. Individual results vary. Anyone considering this should work closely with their diabetes care team and be prepared for frequent monitoring initially. Never change insulin doses or stop medications without consulting your healthcare provider.

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